APTA Comments on Medicare OPPS Rebilling Demo, IRF Quality Reporting

This week APTA responded to 4 specific questions posed by the Centers for Medicare and Medicaid Services (CMS) in its proposed rule for Medicare hospital outpatient prospective and ambulatory surgical center payment systems (OPPS) for calendar year 2013.

The questions are in relation to implementation of the Medicare Part A to Part B Rebilling Demonstration. In this demonstration, participating hospitals are allowed to receive 90% of the allowable Part B payment for Part A short-stay claims that are denied on the basis that the inpatient admission was not reasonable and necessary. The hospitals can rebill denied Part A claims as Part B services and be paid additional reimbursement when an inpatient admission is found not reasonable and necessary. CMS' questions involve setting parameters regarding the amount of time a patient can remain on observation status, establishing specific clinical criteria for admission and payment, aligning hospital payment rates more closely with the resources used to provide outpatient care, and having case management and utilization review staff available in hospitals outside of regular business hours to improve the accuracy of admission decisions.

Additionally, APTA notes its support for 3 proposed changes to the IRF Quality Reporting Program. The changes seek to harmonize the processes for the maintenance of technical specifications and measure removal from the IRF quality program with other quality reporting programs such as those in inpatient hospital settings.